Otology & Neurotology
25:135–138 © 2004, Otology & Neurotology, Inc.
Characterizing and Treating Dizziness after Mild
Head Trauma
Michael E. Hoffer, Kim R. Gottshall, Robert Moore, Ben J. Balough, and
Derin Wester
Department of Defense Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center
San Diego, San Diego, California, U.S.A.
Objective: The objectives of this study were to characterize
patterns of dizziness seen after mild head trauma and to exam-
ine the diagnosis and treatment of this disorder.
Study Design: Prospective patient registry.
Setting: Tertiary referral center.
Patients: Fifty-eight cases of active duty and retired military
personnel who sustained mild head trauma and had resultant
dizziness.
Interventions: Vestibular evaluation, characterization by
group, and treatment.
Main Outcome Measures: Outcome measures include char-
acterization of diagnosis types, patient distribution by diagnosis
type, and patient outcome.
Results: Individuals suffering from dizziness after mild head
injury were divided into three diagnostic groups. Forty-one
percent of the individuals suffered from posttraumatic vestib-
ular migraines, 28% of the individuals had posttraumatic posi-
tional vertigo, and 19% of the individuals were classified as
posttraumatic spatial disorientation. The remaining 12% of the
Mild traumatic brain injury (TBI) is the second most
common neurologic disorder with an incidence of 180 in
100,000 (1). The symptoms of mild TBI include fatigue,
headaches, dizziness, concentration, memory disorders,
and irritability (2). The pathophysiology of TBI is diffuse
axonal injury (DAI), which is caused by shearing forces
in the brain occurring after sudden deceleration (3). DAI
is characterized by axonal loss and Wallerian degenera-
tion, focal edema from small vessel disruption, and the
release of excitatory neurotransmitters, many of which
could be active in apoptotic pathways. The duration of
symptoms in patients with TBI has long been debated.
Although some investigators believe that symptoms only
last weeks to months, many investigators believe that
Address correspondence and reprint requests to Michael E. Hoffer,
CDR MC USN, Codirector, Department of Defense Spatial Orientation
Center, Department of Otolaryngology, Naval Medical Center San Diego,
San Diego, CA 92134-2200; E-mail: mehoffer@nmcsd.med.navy.mil
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the Department of the Navy,
Department of Defense, or the United States Government.
135
patients could not be characterized. The positional group had
objective physical examination findings, which cleared with
treatment in all cases. The migraine group of patients and the
disorientation group of patients had distinct abnormalities of
the vestibulo-ocular reflex (VOR) and the vestibulo-spinal re-
flex (VSR). Eighty-four percent of the migraine group demon-
strated an improvement of these test results as compared with
27% of the disorientation group. Mean time to return to work
was less than 1 week for the positional group, 3.8 weeks for the
migraine group, and greater than 3 months for the disorienta-
tion group.
Conclusions: Using our patient registry of individuals suffer-
ing from dizziness after mild head trauma, we were able to
characterize the majority of these cases into one of three more
specific diagnostic groups. We present diagnostic criteria, sug-
gested treatment guidelines, and our prognostic data. Key
Words: Traumatic brain injury (TBI)—Migraines—Dizziness—
Vertigo—Positional vertigo—Vestibular rehabilitation.
Otol Neurotol 25:135–138, 2004.
symptoms can persist for years or might never com-
pletely resolve (3,4). Complicating the study of TBI
symptoms is the fact that there is not one accepted ob-
jective test that characterizes initial and persistent symp-
toms of TBI. There are three indexes that are available on
most patients at the time of injury or just after the injury.
These include the Glasgow Coma Scale (GCS), presence
or absence of loss of consciousness (LOC), and duration
of posttraumatic amnesia (PTA). However, these mea-
sures are very rough in scale and provide no outcome
data after the time of injury. In addition to the difficulty
in characterizing the severity and duration of mild TBI
and its associated symptoms, there is difficulty in char-
acterizing the symptoms themselves. Many of the signs
and symptoms of the disorder are subtle and other symp-
toms can be confused with each other, making it difficult
to determine when any particular symptom started or
stopped. In particular, little evidence is available charac-
terizing dizziness after mild TBI. The goal of this article
is to examine the patterns of dizziness after mild TBI and
to provide some treatment strategies and prognostic data
for this common disorder.
136 M. E. HOFFER ET AL.

MATERIAL AND METHODS
All patients seen at our vestibular referral clinic were entered
into a computerized database. Over a 2-year period of time, 58
patients were seen who met the criteria of post-mild traumatic
brain injury dizziness. All of the patients had mild TBI as
characterized by a GCS of 13 to 15 and no loss of conscious-
ness. All patients were initially screened by a trauma screening
protocol within 1 to 3 days of their injury as part of an Insti-
tutional Review Board-approved study of mild traumatic brain
injury in active duty military individuals. The diagnosis of mild
TBI was confirmed by this group, and patients were referred to
us for evaluation of any complaints of dizziness. All patients
had vestibular symptoms of imbalance, true vertigo, dizziness,
and/or unsteadiness. All of the individuals had a work-up that
included a detailed otolaryngologic history and physical exami-
nation, standard neurologic examination, and a magnetic reso-
nance scan (MRI) to rule out a cerebellopointine angle lesion or
other pathology. An objective neurovestibular elevation includ-
ing dynamic computerized posturography (Neurocom, Inc.,
Clackamas, OR, U.S.A.), rotational chair testing including si-
nusoids and step-velocity testing (Micromedical, Inc.,
Chatham, IL, U.S.A.), high-speed head velocity testing using a
VORTEQ device and IR goggles (Micromedical, Inc.), dy-
namic visual acuity, and a standard audiogram was performed
on each patient. In addition, a functional test battery consisting
of an impulse head thrust test, Fukuda step test, Romberg test,
tandem Romberg test, and Dynamic Gait Index (DGI) (5) was
administered to each patient. Finally, the Dizziness Handi-
capped Index (DHI) (6) and the Activities-Specific Balance
Confidence Scale (ABC) (5) surveys were administered. To be
included in the study, patients were required to have no previ-
ous pathology or history of dizziness or severe headaches. The
patients were divided into three groups based on their history,
physical examination, and results of the testing. The three
groups were preselected based on our clinic’s experience with
this type of patient. The three groups were posttraumatic posi-
tional vertigo, posttraumatic migraine-associated dizziness
(PTMAD), and posttraumatic spatial disorientation. There were
set diagnostic criteria for each group as documented in Table 1.
Individuals were included in a group if they met the diagnostic
criteria and were assigned into the group by two independent
examiners. In particular, to be included in the PTMAD group,
individuals had to have abnormalities on challenged gait testing
and on high-frequency vestibulo-ocular reflex (VOR) gain test-
ing with normal static posture. In addition, all of the patients in
the migraine-associated dizziness group had approximately a
2-week window between the head trauma and the onset of
headaches and had migraine headaches as classified by the
International Headache System (7). The vestibular symptoms
were reported as an aura before the headache, during the head-
ache, or completely independent of the headaches. The spatial
disorientation group could be distinguished from the migraine
group by the abnormalities on static posture testing (and pos-
turography), the lack of migraine headaches, and the constant
feeling of unsteadiness seen in patients in the disorientation
group. There were some patients who could not be classified
into any of the three groups because they did not meet diag-
nostic criteria, because they had incomplete testing, or because
two investigators did not agree on the classification.
All groups (except for the positional group) underwent a 6-
to 8-week standard vestibular rehabilitation program as docu-
mented in our previous work (8) and then underwent repeat
testing. The vestibular rehabilitation was composed of indi-
vidualized programs of vestibulo-ocular reflex, cervico-ocular
reflex, and somatosensory exercises combined with aerobic ac-
tivity. The groups were compared on three criteria as follows:
1) improvement of objective physical examination and testing
result abnormalities after therapy, 2) average time to return to
work, and 3) average time to return to the perception of normal
balance function based on the DHI and ABC tests. The indi-
viduals in the unclassified group also underwent therapy but
their data was not analyzed in this study.
RESULTS
Fifty-one of the 58 patients seen in the study period
could be classified into one of the three groups. The
posttraumatic positional vertigo group was composed of
16 patients (28%; 12 males and 4 females), the PTMAD
group was composed of 24 individuals (41%; 22 males
and 2 females), and the posttraumatic spatial disorienta-
tion group was composed of 11 individuals (19%; 8
males and 3 females). The average age in the migraine
group and the disorientation group was 30 and 32 years
of age, respectively, whereas the average age of the po-
sitional dizziness group was 42 years of age. Despite this
apparent difference, statistical analysis demonstrated that

TABLE 1. Posttraumatic dizziness classifications

Entity History
Positional vertigo Positional vertigo
Migraine-associated 1. Episodic Vertigo with
dizziness periods of unsteadiness
2. Headaches
3. +/− Positional vertigo
Spatial disorientation 1. Constant feeling of unsteadiness
worsened by standing but still present
when sitting or lying down
2. Drifting to one side while walking
3. Shifting weight when standing still
Physical examination
Nystagmus on Dix-Hallpike test or
modified Dix-Hallpike test
1. Abnormalities in challenged
gait testing
2. +/− Abnormalities on head
impulse testing
3. Normal static posture tests
1. Abnormalities on standard
gait tests
2. +/− Abnormalities on head
impulse testing
3. Abnormalities on static posture
tests
Vestibular tests
No other abnormalities
1. VOR gain, phase, or symmetry
abnormalities
2. High-frequency VOR gain
abnormalities
3. Normal posturography
1. VOR gain, phase, or symmetry
abnormalities
2. High-frequency VOR gain
abnormalities
3. Abnormal posturography
4. Central findings on rotation chair or
VNG testing (VVOR or visual fixation
abnormalities)

VOR, vestibulo-ocular reflex; VNG, vestibulonystagmography: VVOR, visual vestibulo-ocular reflex.

Otology & Neurotology, Vol. 25, No. 2, 2004

 DIZZINESS AFTER HEAD INJURY
the average age and male/female ratio among the three
groups was not statistically different. Both the PTMAD
and posttraumatic spatial disorientation groups had ob-
jective findings of altered VOR function on testing.
These disorders were typically a midfrequency (0.32
and 0.64 Hz) phase shift on sinusoidal rotation chair
testing. In addition, several individuals, from both
groups, displayed an abnormally low gain in the midfre-
quencies on the same test. After 6 to 8 weeks of reha-
bilitation therapy, 84% of the migraine group demon-
strated an improvement in VOR tests as compared with
27% of the disorientation group. This difference was
significant (p <0.01).
The results for the average time to return to work and
the time to the perception of normal are shown in Figure
1. As can be seen, the disability for the disorientation
group is significantly longer than for the other two
groups. It should be noted that the disorientation data is
for patients who returned to work and those whose symp-
toms resolved. At least two individuals are over 1 year
out and have not returned to work or had resolution of
their symptoms.
DISCUSSION
Our series represents one of the larger series examin-
ing dizziness after mild head trauma. The fact that diz-
ziness is associated with mild head trauma has been re-
ported in the literature (3,9). However, very little work is
available documenting the characteristics, evaluation, or
treatment of this dizziness. Most authors feel that the
dizziness will resolve “with time.” The literature quotes
recovery time for the symptoms of mild head injury as 3
to 9 months in most individuals with a persistence of
symptoms for greater than 1 year in 10% to 15% of the
patients (10,11). Our data shows that, depending on the
type of balance disorder, treatment can improve the rate
FIG. 1. Comparison of time to return
to work and time required for symp-
tom remission in three groups of pa-
tients with posttraumatic dizziness.
137
of recovery significantly. The majority of our patients (in
the positional or PTMAD groups) were better in 1 to 8
weeks. It was the disorientation group (19% of our total
population) that had a more protracted course and on
average did not have resolution of symptoms until 39
weeks. Approximately 4% of our population were no
better at the 1-year mark. It appears, then, at least for the
migraine and positional groups of patients, rehabilitation
could have a positive impact by shortening disability
time and speeding return to work. Literature reports the
positive impacts of rehabilitation in migraine-associated
dizziness (MAD) (12,13). It seems this positive benefit
applies to PTMAD as well. It should be noted that there
is some controversy in using the diagnosis of PTMAD.
Although there is support for the existence of this entity
in the literature (3,14), it must be pointed out that PT-
MAD is a functional diagnosis. That is, individuals are
given this diagnosis because they have the same symp-
toms and respond to the same sort of treatment as indi-
viduals with MAD. We cannot prove that the pathophysi-
ology of PTMAD is truly the same as more typical MAD
and must use caution in generalizing the results of treat-
ment modalities in this group of patients to those with
nontraumatic MAD.
Although our study demonstrates the benefits of reha-
bilitation and provides a framework for evaluating post-
traumatic dizziness, there are some areas where more
study is needed. It would be useful to better define our
diagnostic criteria. It is possible that patients could be
assigned a diagnosis without undergoing the entire bat-
tery of tests that we used in this study. It is also possible
that there are more than three groups of patients. Maybe
the individuals who do not recover in 1 year have dif-
ferent pathology and require different treatment modali-
ties. The more precise we can be in making a diagnosis
and the easier that the diagnosis can be made will pro-
duce better care and better outcomes for patients. Finally,
Otology & Neurotology, Vol. 25, No. 2, 2004
138 M. E. HOFFER ET AL.
a controlled study on the impact of rehabilitation in this
group of patients would be helpful from a scientific
standpoint, but might not be possible to conduct from an
ethical standpoint. Instead, we might have to rely on
more studies and the reproduction of this work at other
institutions to help add support to our conclusions.
CONCLUSION
Dizziness is a common symptom after mild head
trauma. Much of the mild head trauma literature focuses
on the other sequelae of this condition and does not
provide much detail in the diagnosis and treatment of
dizziness, which in many patients is their primary dis-
ability. We have looked at a cohort of patients with mild
head trauma and categorized them into three different
dizziness diagnoses. We have provided some diagnostic
criteria and outcome results. In time and with more
study, the diagnostic criteria and specific treatment mo-
dalities for each disorder could be refined, resulting in
improved patient outcomes and shorter disability times.
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